Provider Demographics
NPI:1639263007
Name:FAVIS, JESSICA A (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:FAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SAN PEDRO DR SE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:505-256-2803
Practice Address - Street 1:1501 SAN PEDRO DR SE DEPT OF
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:505-256-2803
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20020032207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87958732Medicaid
H61491Medicare UPIN
NM87958732Medicaid